Injections Research Articles

Hearing Outcomes Following Endolymphatic Duct Blockage Surgery and Factors Associated with Improved Audition at Two Years Follow-Up.

Objective: To evaluate hearing outcomes at 2 years post endolymphatic duct blockage (EDB) surgery, with an analysis of factors that may predict hearing improvement. Study Design: Retrospective comparative study. Setting: Tertiary care center. Subjects: Definite Ménière's Disease (MD) patients undergoing EDB for refractory disease. Methods: Chart review was conducted to assign cases to one of the three hearing outcome groups (deteriorated, stable, and improved). All cases that met our inclusion criteria were selected. Preoperative data collected were audiograms, bithermal caloric tests, preoperative vertigo episodes, history of previous ear surgery for Ménière, intratympanic steroid injections (ITS) and intraoperative endolymphatic sac (ELS) tear or opening. Postoperative data collected at 24 months were audiograms, vertigo episodes and bithermal caloric testing. Results: Preoperative vertigo episodes, caloric paresis and history of surgery, ITS injections or ELS integrity, as well as postoperative vertigo class distribution and caloric paresis changes were not different between our groups. Preoperative word recognition score (WRS) was lowest in the improved hearing group (p = 0.032). The persistence of tinnitus at 2 years postoperatively was associated with deteriorated hearing (p = 0.033). Conclusions: There are no strong predictors of hearing improvement on presentation pre-EDB, but low preoperative WRS may be the best estimator available. Therefore, ablative interventions should be considered very carefully in patients presenting with low WRS, as they may benefit more from EDB; there is a fair chance of a good hearing outcome with EDB surgery. Persistence of tinnitus can reflect deteriorating audition. Vertigo control and hearing preservation are independent outcomes of EDB surgery, making it desirable as an early intervention for refractory MD cases.

O033 Video tuition of intracavernosal alprostadil injection for management of erectile dysfunction

Abstract Introduction Intracavernosal injections (ICI) are the second line treatment of erectile dysfunction (ED). To reduce the risk of complications, primarily priapism, the first administration has traditionally required face-to-face appointments. With a move to remote working, the safety and feasibility of an instructional video for the first self-administration of ICI was assessed. Methods Two centres recruited patients, with participants receiving a pack comprising a written instruction leaflet and a Viridal Duo prescription, followed by an email with our instructional video. Patients were given a specific time to self-administer their ICI (Alprostadil 2.5 micrograms), when our CNS was available for support. The same CNS would follow up two hours later via telephone to assess the experience using a Likert scale semi-structured interview. Results Thirty-nine patients were recruited between two centres, with 35 continuing to injection. The median age was 63 years (range 34–78). The most common ED aetiology was post-prostatectomy (18/35). Thirty-four (97%) recruits found the video instructions clear, with it being watched a mean 2 (range 1–8) times. Only 1 patient (3%) required telephone support. At the 2.5mcg dose, the mean erection hardness score was 2 (range 1–4) after an average of 5 minutes. No patients reported significant bruising at the injection site and there was no priapism. Thirty-three patients (94%) were very or extremely likely to recommend this method for starting ICI therapy. Conclusion Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity. Take-home message Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

Pre- and post-injection pain in patients undergoing first intracavernosal injection

ABSTRACT Introduction Intracavernosal injections (ICI) are a well-established treatment option with great success rates for men with erectile dysfunction. Unfortunately, the anticipation of pain with injections remains a significant barrier to the use of ICI. Objective This study aims to utilize a standardized verbal pain scale to examine the perception of pre- and post-injection pain in men who are undergoing their first injection with an intracavernosal erectile agent. Thus, inclusion criteria required no previous penile injection of any type, including but not limited to erectile medications and collagenase. Methods We determined a prospective pre-post observational study would be best to examine men undergoing their first ICI. Men who had no previous history of intracavernosal injection of any kind were asked to predict the pain associated with their first ICI with a score of zero to ten. Patients then received a 10 microgram (mcg) injection of prostaglandin E1 (PGE1). Immediately after they received their injection, they were asked to rate the pain they perceived with the injection on the same scale (0-10). The same physician administered pre- and post-injection scales in a standardized fashion. Results A total of 17 of men were asked to rate their pain as discussed in the Methods Section. The average age of men sampled was 61.8 years of age. On review of history, 64.7% of men were found to have used some type of PDE-5 inhibitor before visiting our clinic. The majority of men we saw had erectile dysfunction (70.6%) and/or Peyronie's Disease (58.8%). The average pre-injection prediction pain score was 5.29 +/- 1.90; the average post-injection perceived pain score was 1.21 +/- 0.81. Thus, there was an average decrease of over 4 points in predicted pain versus perceived pain. A two-sample t-test was performed; in addition, a Wilcoxson Signed Rank Test was performed. Both tests showed statistical significance in the difference between pre- and post-injection pain scores (p <0.001). Conclusions We found that patients who are undergoing ICI for their first time have a significantly higher prediction of pain versus perception of pain after the injection. We have utilized this data in our clinic to explain to patients that while the majority of patients predict high pain scores associated with injection, the vast majority of patients report very minimal pain associated with the injection. Patients can be more open-minded to ICI therapy which could help aid them with their erectile status; this can particularly be helpful in patients who want to avoid surgery and in patients who are not good surgical candidates. Disclosure Work supported by industry: no, by N/A.

Pre- and Post-injection Pain in Patient's Undergoing First Intracavernosal Injection

ABSTRACT Introduction Intracavernosal injections (ICI) are a well-established treatment option with great success rates for men with erectile dysfunction. Unfortunately, the anticipation of pain with injections remains a significant barrier to the use of ICI. Objective This study aims to utilize a standardized verbal pain scale to examine the perception of pre- and post-injection pain in men who are undergoing their first injection with an intracavernosal erectile agent. Thus, inclusion criteria required no previous penile injection of any type, including but not limited to erectile medications and collagenase. Methods We determined a prospective pre-post observational study would be best to examine men undergoing their first ICI. Men who had no previous history of intracavernosal injection of any kind were asked to predict the pain associated with their first ICI with a score of zero to ten. Patients then received a 10 microgram (mcg) injection of prostaglandin E1 (PGE1). Immediately after they received their injection, they were asked to rate the pain they perceived with the injection on the same scale (0-10). The same physician administered pre- and post-injection scales in a standardized fashion. Results A total of 17 of men were asked to rate their pain as discussed in the Methods Section. The average age of men sampled was 61.8 years of age. On review of history, 64.7% of men were found to have used some type of PDE-5 inhibitor before visiting our clinic. The majority of men we saw had erectile dysfunction (70.6%) and/or Peyronie's Disease (58.8%). The average pre-injection prediction pain score was 5.29 +/- 1.90; the average post-injection perceived pain score was 1.21 +/- 0.81. Thus, there was an average decrease of over 4 points in predicted pain versus perceived pain. A two-sample t-test was performed; in addition, a Wilcoxson Signed Rank Test was performed. Both of these tests showed statistical significance in the difference between pre- and post-injection pain scores (p <0.001). Conclusions We found that patients who are undergoing ICI for their first time have a significantly higher prediction of pain versus perception of pain after the injection. We have utilized this data in our clinic to explain to patients that while the majority of patients predict high pain scores associated with injection, the vast majority of patients report very minimal pain associated with the injection. Patients can be more open-minded to ICI therapy which could help aid them with their erectile status; this can particularly be helpful in patients who want to avoid surgery and in patients who are not good surgical candidates. Disclosure No

Pre- and Post-Injection Needle Pain in Patients Undergoing First Intracavernosal Injection

BackgroundIntracavernosal injections (ICI) are a well-established treatment option for men with erectile dysfunction (ED); however, the anticipation of pain with injection remains a significant barrier to the use of ICI. AimTo evaluate the patient-anticipated degree of pain versus the experienced degree of pain pre- and post-ICI in men undergoing their first injection with an erectile agent. MethodsWe studied 51 patients who underwent their first ICI in our men's health clinic. Anticipated needle-associated pain was judged with a pre-injection score, and pain experienced during the injection was judged with a post-injection score. All patients graded their pre- and post-ICI pain using a standard 10-point scale (0–10). OutcomesPre- and post-ICI pain was defined with the visual analogue scale (0–10) in men undergoing their first penile injection. ResultsMedians and interquartile ranges (IQRs) of the patients' age [65 years (54.5–68.0)], pre-injection pain [5 (4–7)], and post-injection pain [1 (1–2)] were recorded. Most men in the study had erectile dysfunction (68.6%) and/or Peyronie's Disease (64.7%). The average pre-injection prediction pain score was 5.45 ± 2.15; the average post-injection perceived pain score was 1.20 ± 0.73. Thus, there was an average discrepancy of over 4 points in predicted pain vs perceived pain. A paired t-test was performed which showed a statistically significant difference between pre- and post-injection scores (P < .05). A Wilcoxson Signed Rank Test showed statistical significance in the difference between pre- and post-injection pain scores (P < .05). Clinical ImplicationsICI is a safe, effective treatment for patients with ED and is associated with significantly less pain than is anticipated by patients. Strengths & LimitationsThis is the first report to describe the discrepancy between pre-ICI anticipated pain and post-ICI experienced pain. Limitations include an overall small sample size. ConclusionPatients experience significantly less pain with ICI than they anticipate having. This represents an important factor to consider when counseling patients about available ED treatments.Baird B, Wajswol E, Ericson C et al. Pre- and Post-Injection Needle Pain in Patients Undergoing First Intracavernosal Injection. J Sex Med 2022;19:590–593.

One shot to control Pain: Decreasing postoperative opioid use in gynecologic oncology patients with intrathecal opioid injection

ObjectivesTo determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduce postoperative pain and intravenous (IV) opioid use after exploratory laparotomy in major gynecologic surgeries. MethodsA retrospective chart review of 315 consecutive cases of patients who underwent an exploratory laparotomy on the gynecologic oncology service from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. Longitudinal regression analyses were performed to estimate the effect of ITO on changes in outcomes of interest over time, adjusting for potential confounders. Results35% (110/315) received ITO preoperatively. There were no differences in patient age, BMI, previous number of abdominal surgeries, history of opioid dependence, type of gynecologic surgery, or total EBL between the ITO and control groups. Preoperative ITO was associated with a significantly lower IV opioid requirement between 0 and 6 hours after surgery (9.7 ± 8.1 vs 14.3 ± 11.5, p < 0.0001) and between 6 and 12 hours after surgery (2.7 ± 3.8 vs 5.4 ± 9.5, p = 0.0054). There was no statistically significant difference in total hospital stay opioid requirement but median length of stay was increased by 1 day. ConclusionsPreoperative administration of ITO reduced IV opioid requirement in the first 12 hours postoperatively but was associated with median 1 day increase in hospital stay.

Preoperative Intrathecal Opioid Injection on Postoperative Analgesia Requirements in Gynecologic Oncology [37H

INTRODUCTION: Decreasing opioid use during postoperative period is a topic of great ongoing interest. We aimed to determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduced intravenous (IV) opioid use after exploratory laparotomy in gynecologic oncology surgeries. METHODS: A retrospective chart review with institution IRB approval of 314 consecutive gynecologic oncology patients undergoing exploratory laparotomy from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were self-reported post-operative pain levels and IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. The relationship between ITO and primary outcomes of interest were determined using longitudinal regression analysis and adjusted for confounding variables. RESULTS: 34% (107/314) received ITO preoperatively. There were no differences in patient age, BMI, number of prior abdominal surgeries, history of opioid dependence, or EBL between the ITO and control groups. Preoperative ITO was associated with significantly lower IV opioid requirement between 0-6 hours after surgery (9.7±8.1 vs 14.3±11.5, P&lt;.0001) and between 6-12 hours after surgery (2.7±3.8 vs 5.4±9.5, P=.0054). In addition to reduced IV opioid use in ITO group, no differences in self-reported postoperative pain levels were noted in the first 48 hours post-operatively. CONCLUSION: Preoperative ITO reduced postoperative opioid requirement for pain control without negatively affecting patients’ self-reported pain level.

368 Beyond the Pill: Preliminary Data Looking at a Combination of Phosphodiesterase Inhibitors With Low Dose Bimix Intra-urethral Gel for the Management of Erectile Dysfunction

Intracavernosal Trimix/Bimix injections (ICI) and Intraurethral Bimix Gel (BMG) have been used for many years for the treatment of erectile dysfunction (ED). Both are great therapies, but more invasive than oral phosphodiesterase inhibitors (PDE5-I). Unfortunately, PDE5-I sole therapy may not be strong enough for moderate to severe ED. A combination of PDE5-I with a low dose, needle-free, intraurethral gel may be more attractive than a difficult to stabilize, refrigeration required, needle to the penis for the treatment of ED. BMG’s versatility is such that it can be used as a sole therapy, or in combination with oral therapy, PDE5-I. This data provides preliminary data on the combination of BMG and PDE5-I for the treatment of ED. Twenty patients were chosen from a registry of 236 patients who were prescribed BMG. Patients were unsatisfied with current treatment of PDE5-I solo therapy. They were not interested in ICI. They all had attempted BMG as a solo treatment modality and reported an improvement in the quality of their erections but reported an uncomfortable “burning sensation” in the urethra with BMG at high dosages. Higher doses were necessary to achieve the appropriate erection. These patients were then instructed to take one-hour pior to intercourse either a 20mg Cialis, 100mg Viagra or a 200mg of Stendra followed by 0.25ml of BMG, 5-10 minutes prior to intercourse.

Does β-Cell Autoimmunity Play a Role in Cystic Fibrosis–Related Diabetes? Analysis Based on the German/Austrian Diabetes Patienten Verlaufsdokumentation Registry

Research on β-cell autoimmunity in cystic fibrosis (CF)-related diabetes (CFRD) is still rare. We aimed to analyze the frequency of β-cell autoimmunity and the influence on age at diabetes onset, insulin requirement, type of insulin therapy, and hypoglycemic or ketoacidotic events in patients with CFRD compared with antibody-negative patients with CFRD in the Diabetes Patienten Verlaufsdokumentation (DPV) registry. We analyzed data of 837 patients with CFRD in the German/Austrian DPV database by multivariable mixed-regression modeling. In our cohort, 8.5% of patients with CFRD (n = 72) were found to be β-cell antibody positive. There was a female preponderance in this patient group: 65.3 vs. 57.6%. Diabetes onset (median [interquartile range]) was earlier (14.00 [10.15-15.90] vs. 16.10 [13.50-21.20] years; P < 0.005), and insulin dose/kg body weight was higher (0.95 [0.61-1.15] vs. 0.67 [0.33-1.04] IU/kg; P < 0.05). There were also differences in the type of insulin treatment. Insulin pump therapy was used significantly more often in patients with CFRD with β-cell autoimmunity (18.2 vs. 6.4%; P < 0.05). The differences for multiple daily injections (ICT) and conventional therapy (CT) were not significant (ICT: 67.7 vs. 79.0%; CT: 15.2 vs. 14.6). Oral antidiabetic agents were rarely used in both groups. Rate of severe hypoglycemia with coma and rate of ketoacidosis were higher in antibody-positive patients (hypoglycemia with coma: 8.0 vs. 1.4, P < 0.05; ketoacidosis: 9.3 vs. 0.9, P < 0.05). Presence of β-cell autoantibodies in our cohort of patients with CFRD (8.5%) appeared to be greater than in the general population and was associated with female sex, earlier onset of diabetes, and higher insulin requirement. Insulin pump therapy was used significantly more often in patients with β-cell antibodies. Severe hypoglycemia and ketoacidosis were significantly more frequent in CFRD with β-cell autoimmunity compared with β-cell antibody-negative patients with CFRD.

Unilateral high division of right sciatic nerve

A thorough knowledge of pelvis and lower extremity is of paramount importance in providing effective care to patients with lower extremity neuralgia. Neuroanatomy knowledge typically acquired in medical colleges at undergraduate level is limited and may not adequately equip the clinicians to effectively manage a patient with intractable pain of lower extremity especially if the nerves are not following a typical course. Sciatic nerve is the main nerve supplying most of the muscles and all of the joints of lower limb. It is a branch of Sacral plexus that leaves the pelvis usually below the piriformis muscle and after supplying the hamstring compartment divide at the level of apex of popliteal fossa into its two terminal divisions namely; Tibial And Common peroneal nerves. Sometimes Sciatic nerve while in the pelvis divides into its terminal branches that leave the pelvis in a number of ways in relation to piriformis muscle. This high division is responsible for ischalgia, wrongly placed intra-muscular inje ctions and piriformis syndrome. This study is carried out in various medical colleges of Lahore including FMH college of Medicine and Dentistry to update the statistical data provided to the therapist and clinicians managing patients of sciatica, ischalgia or piriformis syndrome.

Efficacy of Concomitant Intratympanic Steroid Injection for Sudden Deafness According to Initial Hearing Loss.

We identified the efficacy and appropriate target group for intratympanic steroid injections (ITS) in patients with idiopathic sudden sensorineural hearing loss (ISSNHL). Retrospective case-control study. Fifty-five ears treated with concomitant ITS and systemic steroids and 165 ears without ITS treatment were identified. Each case had three controls matched according to the age, sex, and the presence of vertigo. Patients were divided into subgroups according to pure tone audiometric configuration and the levels of initial hearing loss. Hearing results and frequency-related hearing gain were investigated. Additional ITS was effective for patients with an ascending type audiogram or patients with Grade 3 (60-90 dB) initial hearing loss. Concomitant ITS, however, resulted in a negative effect on hearing in patients with Grades 1 and 2 (<60 dB). ITS resulted in significant (p < 0.05) hearing improvement at 250 Hz in the Grade 3 (60-90 dB) and Grade 4 (>90 dB) ITS subgroups. The efficacy of additional ITS for ISSNHL was different among subgroups with various levels of initial hearing loss or audiogram configuration.

Increased Endothelial Apoptotic Cell Density in Human Diabetic Erectile Tissue—Comparison with Clinical Data

Erectile dysfunction (ED) is a common complication of diabetes. Endothelial cell (EC) dysfunction is one of the main mechanisms of diabetic ED. However, loss of EC integrity has never been assessed in human diabetic corpus cavernosum. To identify and quantify apoptotic cells in human diabetic and normal erectile tissue and to compare these results with each patient's clinical data and erection status. Eighteen cavernosal samples were collected, 13 from diabetics with ED and 5 from nondiabetic individuals. Cavernosal structure and cell proliferation status were evaluated by immunohistochemistry. Tissue integrity was assessed by terminal transferase dUTP nick end labeling assay, an index of apoptotic cell density (ACD) established and compared with each patient age, type of diabetes, arterial risk factors number, arterial/veno-occlusive disease, response to intracavernous vasoactive injections (ICI), and penile nitric oxide release test (PNORT). Establish an index of ACD and correlate those results with patient clinical data. Nondiabetic samples presented few scattered cells in apoptosis and an ACD of 7.15 +/- 0.44 (mean apoptotic cells/tissue area mm(2) +/- standard error). The diabetic group showed an increased ACD of 23.82 +/- 1.53, and apoptotic cells were located specifically at vascular sites. Rehabilitation of these endothelial lesions seemed impaired, as no evidence of EC proliferation was observed. Furthermore, higher ACD in diabetic individuals correlated to poor response to PNORT and to ICI. We provided evidence for the first time that loss of cavernosal EC integrity is a crucial event involved in diabetic ED. Furthermore, we were able to establish a threshold between ACD values and cavernosal tissue functionality, as assessed by PNORT and vasoactive ICI.

Success rate of unilateral spinal anesthesia is dependent on injection flow

Background and Objectives: The dependence of unilateral spinal anesthesia on injection flow is controversial. We hypothesized that it is possible to achieve strictly unilateral sympathetic block (as assessed by temperature measurements of the limbs) and unilateral sensory and motor block, respectively, during spinal anesthesia by a slow and steady injection of a hyperbaric local anesthetic solution. Methods: Forty-four patients (American Society of Anesthesiologists [ASA] physical status I-III) undergoing surgery of one lower extremity were randomly assigned to one of two groups. Dependent on the patients` height, 1.4 to 1.7 mL hyperbaric bupivacaine 0.5% was injected manually with the patient in the lateral decubitus position, which was maintained for 30 minutes after injection. Injection flow was approximately 0.5 mL/min in group I (“air-buffered” injections performed by 4 mL air between the local anesthetic and the syringe's plunger, n = 25) and approximately 7.5 mL/min in group II (“conventional” injections, n = 19). Sympathetic block was defined as a temperature increase of more than 0.5°C at the foot. Any reduction in the ability to move the hip, knee, or ankle as well as loss of temperature discrimination and/or pinprick even in one dermatome on the nondependent side was considered as a bilateral block. Results: Before surgery, significant differences ( P < .05) were observed for unilateral motor paralysis (92% in group I v 68.4% in group II), unilateral sensory block (48.0% v 10.5%), and unilateral sympathetic block (72% v 42.1%). Strictly unilateral spinal anesthesia was found to be significantly more frequent in group I (40% v 5.3%). Significant hemodynamic differences between the groups were not detected. Conclusions: For hyperbaric spinal anesthesia, the injection flow is an important factor in achieving unilateral sympathetic block. A slow injection proves useful to restrict spinal anesthesia to the side of surgery. Reg Anesth Pain Med 2001;26:420-427.

Immunotherapy with aluminum hydroxide adsorbed insect venom extracts (Alutard SQ): immunologic and clinical results of a prospective study over 3 years.

This prospective study over 3 years investigated the safety, immunogenicity, and effectiveness of immunotherapy (IT) with aluminum hydroxide adsorbed insect venom extracts (Alutard SQ, ALK Laboratories) in patients with previous, severe, systemic, IgE-mediated, anaphylactic reactions to Hymenoptera stings. Seventeen patients were treated with honeybee venom (BV), 13 with yellow-jacket venom (YJV), and 5 with both. No severe reactions to IT were noted. Only 3 BV-allergic patients experienced mild systemic reactions of grades I or II (1 per 139 injections) during the increase phase. As for the immunologic data, there was a significant decrease in specific IgE antibodies after 1 year, and a significant increase in specific IgG and IgG4 antibodies on reaching the maintenance dose, with a further rise after 1, 2, and 3 years. Moreover, a significant decrease in anti-IgE autoantibodies was observed in the BV group. Out of the 11 patients that were occasionally restung by the relevant insect (totaling 19 stings in all), only one patient developed mild systemic allergic symptoms after a third sting. In view of these results, we consider IT with aluminum hydroxide adsorbed insect venom extracts to be safe, immunogenic, and effective. The low rate of side-effects may be due to the slow release of the venom in the aluminum hydroxide adsorbed form.

Studies on the Change of Physical and Chemical Characters caused by Mixing of Injections (II)

Studies on the Change of Physical and Chemical Characters caused by Mixing of Injections (II)